[Juvenile osteochondrosis and osteonecrosis]

BACKGROUND

Juvenile osteonecrosis is an important topic in orthopedics. A wide variety of body regions of the growing patient are affected, predominantly during adolescence. All are characterized by a usually unknown aetiology as well as a stadium-like course. The main problem is a local osseous circulatory disorder, which causes osteonecrosis.

RISK FACTORS

Mechanical overloading due to increased body weight, axial misalignment, and sports activity is discussed as a risk factor. Healing depends on the localization and extent of the osseous necrosis.

DIAGNOSTICS

Diagnostically, radiologic imaging is used, in which the typical bony remodeling can be followed.

THERAPY

The therapeutic procedure depends on the affected region but is usually accompanied by a reduction of mechanical loading. If the clinical and radiological findings worsen, surgical treatment must be considered. The recognition and treatment of juvenile osteonecrosis is important and significantly influences the further development of the patient.

Autologous osteochondral transplantation method of treatment for patellar osteochondral lesions

PURPOSE

This study evaluated the functional and clinical outcomes of the subjects with symptomatic osteochondral lesions on articular surface of patella, who were treated with autologous osteochondral transplantation (AOT) method.

STUDY PLAN

AOT method was applied for the treatment of 14 subjects (eight men and six women; mean age 29.7 years; range 19-49 years) with symptomatic patellar osteochondral lesions between March 2008 and April 2013. After a mean follow-up period of 3.7 years (range 32-80 months), pre- and postoperative clinical and functional evaluations of the patients were performed using Visual Pain Scale (VPS), Lysholm Knee Scoring Scale, and Kujala Anterior Knee Pain Scale. Wilcoxon test was used for statistical evaluation of pre- and postoperative outcomes. Improvement of the lesions was assessed by magnetic resonance imaging (MRI) at year 1 postoperatively at the earliest.

RESULTS

The mean lesion size was 1.32 cm² (range 0.8-1.8 cm²). The mean pre- and postoperative VPS values were calculated to be 75.5 ± 12.32 (range 46-92) and 17.57 ± 10.21 (range 0-40), respectively ( p < 0.01). The mean pre- and postoperative Lysholm knee scores were 44.57 ± 9.35 (range 26-65) and 80 ± 6.9 (range 70-94), respectively ( p < 0.01), and the mean pre- and postoperative Kujala anterior knee pain scores were 48.21 ± 7.78 (range 38-68) and 78.42 ± 7.06 (range 70-96), respectively ( p < 0.01). MRI taken at year 1 postoperatively showed that the autograft bone tissue was sufficiently incorporated into the recipient site in all patients; an even articular surface was formed, but the thickness of the cartilage tissue was mostly uneven between the adjacency of the recipient site and the autograft, which caused no negative effect on clinical and functional outcomes.

CONCLUSIONS

Despite the difference in thickness of the cartilage tissue between the recipient and the donor site, the AOT technique for the treatment of patellar osteochondral lesions resolves the symptoms of the patient and ensures an apparent functional and clinical improvement even if an articular surface could be created.

Van Neck-Odelberg disease in a 8-year-old children: a rare case report

INTRODUCTION

osteochondrosis of ischiopubic synchondrosis (IPS)" also known as van Neck- Odelberg disease (VNOD), is a syndrome characterized by an atypical ossification pattern of the ischiopubic joint. Because of its non-unequivocal radiological features, which can mimic stress fracture, infection disease, neoplasm or post-traumatic osteolysis, these different diagnoses need to be rule out.

CASE PRESENTATION

We present an 8-year-old, obese, right limb dominant child that complained only slight groin pain and a limp on left side for more than 20 days. Neither the patient nor his parents recall any trauma. On clinical examination, no swollen lymph nodes were noticeable. After digital pressure, the patients reported a dragging feeling in the left groin, radiating into the medial left thigh and limitation of Range of Motion (ROM) were present. Thus, a plain X-ray and MRI were performed, revealing VNOD on left ischiopubic ramus. The boy was then treated with regular NSAID and pain adapted full weight bearing and a clinical check at 30 and 60 days was performed. At the last visit, the symptoms were completely disappeared and the patient totally recovered left hip function.

CONCLUSION

Diagnosis of VNOD is challenging and clinical presentation is not pathognomonic. So, other benign or severe conditions need to be rule out. Once this disease is diagnosed, the prognosis is generally favourable.

Screening of the Maturity Status of the Tibial Tuberosity by Ultrasonography in Higher Elementary School Grade Schoolchildren

This study aimed to obtain screening data on the maturity status of the tibial tuberosity in schoolchildren of higher elementary school grades for risk management of Osgood-Schlatter disease (OSD). The maturity stages and cartilage thicknesses at the tibial tuberosity were determined by ultrasonography on the occasion of a school-based musculoskeletal examination for 124 grade 5-6 elementary schoolchildren, and their associations with the students' demographic characteristics and OSD were examined. The time-dependent changes of the maturity status of the tibial tuberosity were also examined in grade 5 students (n = 26) by a longitudinal survey. The cross-sectional survey showed that the epiphyseal stage was reached in 89% of girls and 35% of boys. The girls who had experienced menarche (n = 28) were all in the epiphyseal stage and had a decreased cartilage thickness (p = 0.004, after adjusting maturity stages). Students with OSD (n = 5) were all girls in the epiphyseal stage, and only two of them had an increased cartilage thickness. During the longitudinal survey, a marked increase in cartilage thickness from the previous measurement was observed in three boys (without clinical symptoms) and a girl who newly developed OSD. Two students with OSD without chronic pain had thin cartilage. In conclusion, for schoolchildren of higher elementary school grades, the risk of OSD is higher among girls with the epiphyseal stage. Cartilage thickness may not contribute to the diagnosis of OSD, since thick cartilage is not very common in OSD. However, cartilage thickness may reflect the status of OSD.

Synovial Fluid Metabolites Differentiate between Septic and Nonseptic Joint Pathologies

Osteoarthritis (OA), osteochondrosis (OC), and synovial sepsis in horses cause loss of function and pain. Reliable biomarkers are required to achieve accurate and rapid diagnosis, with synovial fluid (SF) holding a unique source of biochemical information. Nuclear magnetic resonance (NMR) spectroscopy allows global metabolite analysis of a small volume of SF, with minimal sample preprocessing using a noninvasive and nondestructive method. Equine SF metabolic profiles from both nonseptic joints (OA and OC) and septic joints were analyzed using 1D 1H NMR spectroscopy. Univariate and multivariate statistical analyses were used to identify differential metabolite abundance between groups. Metabolites were annotated via 1H NMR using 1D NMR identification software Chenomx, with identities confirmed using 1D 1H and 2D 1H 13C NMR. Multivariate analysis identified separation between septic and nonseptic groups. Acetate, alanine, citrate, creatine phosphate, creatinine, glucose, glutamate, glutamine, glycine, phenylalanine, pyruvate, and valine were higher in the nonseptic group, while glycylproline was higher in sepsis. Multivariate separation was primarily driven by glucose; however, partial-least-squares discriminant analysis plots with glucose excluded demonstrated the remaining metabolites were still able to discriminate the groups. This study demonstrates that a panel of synovial metabolites can distinguish between septic and nonseptic equine SF, with glucose the principal discriminator.

Pediatric Pain Syndromes and Noninflammatory Musculoskeletal Pain

Chronic musculoskeletal pain (CMP) is one of the main reasons for referral to a pediatric rheumatologist and is the third most common cause of chronic pain in children and adolescents. Causes of CMP include amplified musculoskeletal pain, benign limb pain of childhood, hypermobility, overuse syndromes, and back pain. CMP can negatively affect physical, social, academic, and psychological function so it is essential that clinicians know how to diagnose and treat these conditions. This article provides an overview of the epidemiology and impact of CMP, the steps in a comprehensive pain assessment, and the management of the most common CMPs.

To be blamed or pitied? The effect of illness on social behavior, cytokine levels and feed intake in undocked boars

Tail biting is detrimental to animal welfare and has negative consequences for producer economy. Poor health is one of the risk factors for tail biting. The first aim of this study was therefore to test for links between health status and behavior related to tail biting at the individual level. The second aim of this study was to test whether variation in cytokines was related to variation in social behavior. These small molecules produced upon immune activation are known to influence behavior both in the direction of withdrawal and increased aggression. This could potentially increase non-functional social behavior and thereby the risk of a tail biting outbreak. To investigate this, we collected behavioral data, health data, feeding data and blood samples from undocked boars at a test station farm in Norway. We compared groups with three different diagnoses: osteochondrosis diagnosed by computer tomography scanning (OCSAN), osteochondrosis diagnosed by clinical examination (OCCLIN) and respiratory tract disease (RESP), with healthy controls (CTR). We tested whether the diagnoses were associated with feeding and growth, social behavior and cytokine levels. We then tested whether there were correlations between cytokine levels and social behavior. We also provide raw data on cytokine levels in the extended sample (N=305) as there are few publications on cytokine levels measured in pigs living under commercial conditions. OCCLIN pigs visited the feeder less, and fed longer compared to CTR pigs. Pigs diagnosed with RESP showed a large drop in growth the first week after filming, which corresponds to the week they were likely to have been diagnosed with illness, and a tendency to compensatory increase in the week after that. Social behavior differed between experimental groups with OCSCAN pigs receiving more social behavior (both aggressive and non-aggressive) compared to CTR, and RESP pigs tending to perform more ear- and tail-biting than controls. There were no differences in absolute levels of cytokines between categories. However IL1-ra and IL-12 showed correlations with several behaviors that have been shown by others to be associated with current or future tail biting activity. To our knowledge, this is the first published study indicating a role for illness in non-functional social behavior in pigs and the first showing a correlation between cytokine levels and social behavior.

Management of bow legs in children: A primary care protocol

OBJECTIVE

To reduce unnecessary orthopedic referrals by developing a protocol for managing physiologic bow legs in the primary care environment through the use of a noninvasive technique that simultaneously tracks normal varus progression and screens for potential pathologic bowing requiring an orthopedic referral.

METHODS

Retrospective study of 155 patients with physiologic genu varum and 10 with infantile Blount`s disease. We used fingerbreadth measurements to document progression or resolution of bow legs. Final diagnoses were made by one orthopedic surgeon using clinical and radiographic evidence. We divided genu varum patients into 3 groups: patients presenting with bow legs before 18 months of age (MOA), patients presenting between 18 and 23 MOA, and patients presenting at 24 MOA or older for analyses relevant to the development of the follow-up protocol.

RESULTS

Physiologic genu varum patients walked earlier than average infants (10 months vs 12-15 months; P<.001). Physiologic genu varum patients presenting before 18 MOA demonstrated initial signs of correction between 18 and 24 MOA and resolution by 30 MOA. Physiologic genu varum patients presenting between 18 and 23 MOA demonstrated initial signs of correction between 24 MOA and 30 MOA and resolution by 36 MOA.

CONCLUSION

Primary care physicians can manage most children presenting with bow legs. Management focuses on following the progression or resolution of varus with regular follow-up. For patients presenting with bow legs, we recommend a follow-up protocol using mainly well-child checkups and a simple clinical assessment to monitor varus progression and screen for pathologic bowing.

Guided growth for tibia vara (Blount's disease)

Blount's disease is commonly attributed to an intrinsic, idiopathic defect in the posteromedial proximal tibial physis resulting in progressive bowing of the leg, intoeing, and lateral knee thrust. Treatment has historically included bracing, physeal stapling, or corrective osteotomy, and was determined primarily by age at presentation. As we feel the pathology is not necessarily age dependent, we have elected to use the technique of guided growth using a lateral tension band plate to correct limb alignment as a first-line treatment in all patients presenting to our clinic as long as they had growth remaining and no evidence of a physeal bar.We identified 17 patients with tibia vara (27 limbs) who were managed by means of guided growth of the proximal tibia, from age 1.8 years to 15.1 years. Clinical and radiographic parameters were followed pre- and postoperatively. The response to guided growth was documented as were any related complications.Twenty-one (78%) limbs had complete normalization of their mechanical axis (middle 50% of knee). Time to correction averaged 13.5 months (8-19 months). There were no peri-operative complications. We observed hardware failure in 3 patients; 2 with screw breakage and 1 patient with hardware migration, none requiring subsequent osteotomy or further treatment. Two patients had rebound varus: one is being observed and another has undergone a repeat procedure.Patients with pathologic tibia vara present at various ages and have historically undergone various treatments ranging from bracing to tibial osteotomy based on age at presentation. We have found that guided growth utilizing tethering plates can be used effectively as first-line treatment in all patients with growth remaining. This minimally invasive method is predictable and well tolerated. Recurrent deformity, though unlikely, is easily remedied by repeating the process and does not preclude osteotomy if eventually needed. Concomitant resolution of ligamentous laxity and inward torsion can be anticipated as the mechanical axis is restored to neutral. The only contraindications for guided growth include an unresectable physeal bar or skeletal maturity.

[OSGOOD-SCHLATTER DISEASE]

Osgood-Schlatter disease is a specific disorder related to osteochondropathies that affects young subjects and is localized in the tuberositas tibiae. The disease frequently develops after injuries including loading ones. It is apparent as gradual swelling of the knee joint(s) that becomes painful. Pain increases during walking, lower limb flexion an extension or stair climbing but may die down at rest. Diagnostics is based on the clinical picture. Radiodiagnostic methods my be helpful but their efficacy is inferior to that of clinical examination. Anti-inflammatory and chondroprotective therapy, immobilization of the affected joint, controlled exercises, and balneotherapy are indicated.

Köhler disease: an infrequent or underdiagnosed cause of child's limping?

Köhler disease (KD) is the osteochondrosis of the tarsal navicular bone of the young children, which is a self-limited condition. Typically the child reports pain with mechanical characteristics in the medial region of the foot, however, intermittent or continuous limping may be the only clinical manifestation, which delays the diagnosis and consequently exposes to unnecessary tests and treatments. We describe a bilateral KD whose clinical manifestation was unilateral limping with 4 months evolution. The radiologic evaluation showed flattening, sclerosis and irregular rarefaction of both navicular bones. Claudication persisted for four weeks, after which, the child remains asymptomatic.

[How I treat ... Osgood-Schlatter disease]

Osgood-Schlatter disease (osteochondosis of the tibial tubercle) is a common and benign disease which usually affects sportpracticing teenagers during their adolescence. Traditionally, its treatment includes total restriction from sport during several months. The latest recommendations, however, are more lenient and adapt all restriction of such practice to the level of pain experienced by the patient. Indeed, this pathology is unlikely to generate any complication and potential sequelae should be surgically managed once the patient has reached adulthood.

Sever's disease complicated with osteomyelitis

Sever's disease is juvenile osteochondrosis of calcaneus, manifested with posterior heel pain and mild swelling, usually in young athletes, caused by repetitive microtrauma. The standard diagnostic procedures include radiographs and ultrasound examination. It is a self-limiting condition, usually treated conservatively. We present a case of Sever's disease complicated with calcaneal osteomyelitis. A 9-year-old boy with a several month history of left heel pain was admitted to our institution for further clinical evaluation and therapy. Bilateral Sever's disease was clinically diagnosed, confirmed by radiographs and ultrasound examination. Magnetic resonance imaging (MRI) showed osteolytic zone in the posterior left calcaneus with peripheral enhancement after contrast administration and surrounding bone and subcutaneous edema, suggestive of osteomyelitis. After six weeks of parenteral antibiotic treatment, the patient's condition improved. Follow up MRI performed 3 months later showed significant regression of osteolytic lesion and replacement with granulation tissue surrounded with new bone formation. To our knowledge and literature search, this is a previously unreported complication of Sever's disease. MRI should be done in all atypical cases of Sever's disease to rule out any other possible disorders including osteomyelitis.

[Osteochondrosis as a possible cause of pharyngeal dysphagia]

Dysphageal complaints in a 65-year-old woman were regarded as a manifestation of mental illness. The autopsy of the patient weighing 32 kg who died from bilateral pneumonia revealed 9-mm osteophytes on the anterior surface of the cervical spine as the cause of dysphagia. Twenty-nine cases of cervical osteochondrosis-induced dysphagia, published in the literature, were analyzed.

Multimodality neurophysiological monitoring during tibial/fibular osteotomies for preventing peripheral nerve injuries

Previously, intraoperative neurophysiological monitoring was not used routinely during tibial osteotomies. In an attempt to improve the post-operative outcomes and reduce known neurologic complications, we used discrete multimodality recording and stimulation models to identify areas of motor and sensory function in eighteen (18) pediatric patients presenting with Tibia Vara (Blount's Disease). By using both posterior tibial and peroneal nerves somatosensory evoked potentials (SSEPs) with transcranial electrical motor evoked potentials (TCeMEPs) precise status of sensory and motor pathways was possible during surgical correction. Similarly, spontaneous electromyography (s-EMG) and triggered electromyography (t-EMG) were used to more accurately localize nerve irritation. Concerns during tibial and fibular osteotomies included ipsilateral lower limb motor and sensory function, especially peroneal nerve injuries due to the location of the osteotomy at the fibular neck. Surgical interventions consisting of additional fibular resection were made during the index procedures for four patients because of real-time monitoring changes noted as the peroneal nerve was entrapped in three patients at the osteotomy site. In fourth patient, the tourniquet pressure was the cause for loss of ipsilateral SSEPs and TCeMEPs. After appropriate surgical intervention, monitoring parameters began to normalize and postoperatively the patients presented with no neurologic deficit. In this study, the application of multimodality recording and stimulation models were utilized including posterior tibial nerve and peroneal nerve SSEP with lumbar potential (LP) identification to compare with contralateral limb recordings. In addition, by using spontaneous and triggered EMG and TCeMEP, we were able to perform monitoring with a high level of confidence throughout surgery.

[Sinding-Larsen-Johansson disease: analysis of the associated factors]

AIM

To analyse the clinical symptoms, aetiology and biomechanical aspects related to Sinding-Larsen-Johansson (SLJ) disease.

MATERIAL AND METHOD

A case control study was conducted, analysing the following variables: age, gender, clinical follow up, side of body with the symptoms, sporting activity, radiological stage, presence of patella alta, presence of short hamstring tendons, and increased posterior tibial slope.

RESULTS

A total of 15 knees in 14 patients were studied; one case with bilateral disease. The large majority of cases were 85.7% were male, and the mean age was 10.86 (standard deviation 1.61). All of them practised sport and physical activity at a high level with a variable duration of symptoms (1-36 months). There was predominance in side. The majority were radiological grade II (53.3). The data analysis did not show any significant difference (P>.05) between the study groups regarding the Caton and modified Insall indexes. There was a significant difference in the popliteal angle measured in the affected knees (mean: 32.50, SD: 8.9) compared with the control group (mean: 17.67, SD: 8.21). The difference in the posterior slope angle in the affected knees was also statistically significant (mean: 10.47, SD: 2.82) compared with the control (mean: 8.33, SD: 1.4).

CONCLUSIONS

According to our data, patients have short hamstring tendons and increased posterior tibial slope compared to the control group, and this difference is statistically significant.

Periosteal chondroma of the proximaltibia mimicking Osgood-Schlatter's disease

We report a case of a periosteal chondroma of the proximal tibia in an 11-year-old girl, which was initially misdiagnosed as Osgood-Schlatter's disease. The absence of pain and meticulous analysis of the imaging findings on initial and follow-up plain radiographs, ultrasound and MRI allowed to suggest the diagnosis of a periosteal chondroma, which was confirmed after biopsy. Besides the difficulty in the imaging diagnosis of the lesion, determination of the optimal treatment strategy may be challenging as well. Given the localization of this lesion close to the growth plate, decision has to be made whether the lesion will be treated surgically or a waitful watching policy will be implemented in order to prevent interference with the normal growth of the bone.

Osteochondrosis: common causes of pain in growing bones

Osteochondrosis is a term used to describe a group of disorders that affect the growing skeleton. These disorders result from abnormal growth, injury, or overuse of the developing growth plate and surrounding ossification centers. The exact etiology of these disorders is unknown, but genetic causes, repetitive trauma, vascular abnormalities, mechanical factors, and hormonal imbalances may all play a role. Legg-Calvé-Perthes disease is a hip disorder that causes hip pain, an atraumatic limp, and knee pain. Osgood-Schlatter and Sinding-Larsen-Johannson diseases are common causes of anterior knee pain that is aggravated by jumping activities and kneeling. Sever disease causes heel pain that is exacerbated by activity and wearing cleats. It often mimics Achilles tendinitis and is treated with activity and shoe modifications, heel cups, and calf stretches. Freiberg disease and Köhler bone disease often cause foot pain and are disorders of the metatarsal head and navicular bone, respectively. Radiographs show sclerosis, flattening, and fragmentation of bone in both diseases. Elbow pain can be caused by medial epicondyle apophysitis or Panner disease. Medial epicondyle apophysitis is exacerbated by frequent throwing and is treated with throwing cessation and acetaminophen or nonsteroidal anti-inflammatory drugs. Panner disease is the most common cause of lateral-sided elbow pain in children younger than 10 years. It may or may not be associated with frequent throwing, and it resolves spontaneously. Scheuermann disease causes back pain and a humpback deformity from vertebral bone anterior wedging.

[Bone and joint diseases in children. Etiology and pathogenesis of osteochondral lesions in children. Osteochondritis dissecans and osteochondrosis]

Osteochondral lesions in children mainly occur in the physeal and epiphyseal cartilage. Osteochondritis dissecans and osteochondrosis (apophysitis) are common and clinically important chronic disorders. These etiology and pathogenesis have also been well investigated in the Veterinary medicine in recent years. One of the most likely causes is proposed as a failure of blood supply to growth cartilage and following focal disturbance of endochondral ossification. Mechanical stress, trauma, rapid growth, anatomic conformation, and dietary imbalances would modify this initial step and break down the normal structure. In human, above-mentioned pathological changes can be detected using recent MRI technology, which contribute quite much in the early diagnosis of lesions in clinic. Another problem in children is acute traumatic growth plate injury, which increases the risk of the early closure of growth plate and following deformity of bone and joint. Early diagnosis and precise treatment are extremely important for children to prevent residual deformity and pain and growth disturbance. In future, less-invasive as well as effective treatments for the focally disturbed or accelerated ossification should be developed.

[A boy with a painful foot]

A 4-year-old boy visited the emergency department with a painful foot. We diagnosed osteochondrosis of the tarsal navicular, also known as Köhler's disease. The patient was successfully treated with a plaster bandage for 4 weeks.

[Spondylogenic visceropathies]

A group of 830 patients with spondylogenic visceropathies was divided into three with clinical symptoms of bronchial (n = 80), cardiac (n = 530), and abdominal (n = 220) vertebral syndromes. Their clinical features, differential diagnosis and methods of treatment are described.

[Osgood-Schlatter disease]

Osgood-Schlatter disease is a painful affection of the knee which touches particularly the active teenagers. Etiology of this frequent affection is unknown. This disease appears as an anterior knee pain and swelling started and worsened by the sports activities. Diagnosis is especially clinical. X-Rays, ultrasounds or IRM are not necessary for the diagnosis. Treatment is based on eviction of sports, analgesics and sometimes physiotherapy. Surgery is rarely proposed. Knee pain stops at the end of the growth. Long-term outcome is good for the majority of the patients. Some studies suggest a patella alta at the end of the growth, without an established correlation with knee arthritis.

[Superior laryngeal nerve neuropathy]

Clinical examination of 28 patients with superior laryngeal nerve neuropathy along with X-ray and electromyographic studies has demonstrated that the disease was associated with cervical spine osteochondrosis. The latter condition was responsible for myofixation, conjugation of laryngeal ligaments and fascii that resulted in the compression of superior laryngeal nerve.

Ultrasonography of the calcaneus in Sever's disease

Severs disease (calcaneal apophysitis) is a self-limiting condition seen in physically active children. Although there is controversy about the radiographic appearance, some reports propose the importance of fragmentation of the secondary nucleus in the diagnosis of Severs disease. We studied secondary nucleus of the calcaneus with ultrasonography. Twenty-one symptomatic heels of 14 children were examined. All these heels showed fragmentation of the secondary nucleus on both conventional radiograph and sonography. Ultrasonographic examination also showed 2 retrocalcaneal bursitis. Our initial data showed that sonography may be valuable in the diagnosis of Severs disease.